Management of Diaphragmatic Dysfunction

Diagnostic Assessment

Diaphragmatic ultrasound is recommended as a bedside tool to assess diaphragmatic function, particularly in patients being weaned from mechanical ventilation 3
Transdiaphragmatic pressure measurement requires simultaneous recordings of esophageal and gastric pressures to assess diaphragmatic contribution to breathing 3
Phrenic nerve stimulation techniques provide objective assessment of diaphragm function independent of patient effort 4
A negative gastric pressure to transdiaphragmatic pressure ratio indicates severe diaphragmatic dysfunction or paralysis 3

Initiate non-invasive ventilation promptly in patients with diaphragmatic dysfunction showing signs of respiratory distress or hypercapnia 1, 2
Avoid excessive oxygen administration in isolation as it can worsen hypercapnia; target oxygen saturation of 88-92% in adults or above 92% for children 5
Monitor CO2 levels closely with transcutaneous monitoring or arterial blood gases 5
Consider controlled ventilation modes as patient triggering may be ineffective 1

If non-invasive ventilation fails, do not delay intubation unless escalation to invasive mechanical ventilation is not desired by the patient or deemed inappropriate 1, 2
In the setting of single organ respiratory failure with diaphragmatic dysfunction, the prospects of recovery are good and invasive ventilation should be considered when non-invasive ventilation is unsuccessful 5
Plan extubation carefully and perform in a specialist center with non-invasive ventilation and mechanical insufflator-exsufflator support available following extubation 5

Diaphragmatic dysfunction is a major cause of weaning failure 3
Before initiating weaning, ensure the precipitant cause of respiratory failure is treated, pH is normalized, and chronic hypercapnia is corrected 2
Physiotherapy treatment is recommended before and after extubation to reduce weaning duration and risk of extubation failure 6
Consider prophylactic non-invasive ventilation after extubation for patients at high risk of reintubation 6

Following an episode of acute hypercapnic respiratory failure, nocturnal non-invasive ventilation should usually be continued pending discussion with a home ventilation service 1, 2
Advance care planning, particularly around the potential future use of invasive mechanical ventilation, is recommended in patients with progressive neuromuscular disease 1, 2
Ensure an individualized emergency healthcare plan is in place and discussed with the patient and family for future hospital admissions 5